1) QualChoice considers allograft transplant of the knee (anterior cruciate ligament, osteochondral, and meniscus) medically necessary when selection criteria are met.
a) Anterior Cruciate Ligament (ACL):
i) Members with ACL deficiency who are not candidates for autogenous transplantation (e.g., individuals whose autogenous tissues have been compromised by previous surgery, previous injury), or
ii) Members with pathology such as chronic patellar tendonitis, and hamstring injury, or
iii) Members with any other contra-indications to using their own tissue such as collagen disease or generalized ligamentous laxity.
i) Treatment of an isolated, traumatic injury that is full-thickness depth (grade 4, down to and/or including the bone) lesion, preferably surrounded by normal, healthy (non-arthritic) cartilage. The opposing articular surface should be generally free of disease or injury; or
ii) Non-repairable stage 3 or 4 osteochondritis dissecans; or
iii) Avascular necrosis lesions of the femoral condyle; or
iv) Otherwise healthy, active members who have either failed earlier arthroscopic procedures or are not candidates for such procedures because of the size, shape, or location of the lesion.
i) Members under the age of 45, and
ii) Pre-operative studies (MRI or previous arthroscopy) reveal absence or near-absence of the meniscus, and
iii) Degenerative changes must be absent or minimal, and
iv) Knee must be stable (i.e., intact or reconstructed ACL).
2) QualChoice considers osteochondral allograft of talus experimental and investigational because there are unanswered questions regarding the clinical outcomes of this approach when compared with ankle arthrodesis, especially in terms of pain, disability, function, and durability.
3) QualChoice considers autologous osteochondral mosaicplasty experimental and investigational because its effectiveness in the treatment of articular cartilage defects/lesions has not been established.
4) QualChoice considers osteochondral autograft transfer system (OATS) experimental and investigational because its effectiveness in the treatment of articular cartilage defects/lesions has not been established.
Codes Used In This BI:
27415 Ostrochondral Allograft, knee, open;
27416 Ostrochondral Autograft, knee, open; (eg, mosaicplasty)
29866 Arthroscopy, Knee, Surgical; osteochondral autograft(s)
29867 Arthroscopy, knee, surgical; osteochondral allograft;
29868 Arthroscopy, knee, surgical; meniscal transplantation, medial or lateral